Acne Vulgaris: A Modern Disease With an Ancient Solution

The chronic skin disease acne vulgaris is today so common that it’s by many considered a natural part of human life. The vast majority of people in industrialized societies get acne sometime during their life. Whereas some only get the occasional blemish during their teenage years, others get severe cysts that leave deep, lifelong scars and ruin their quality of life.

I got quite a bit of pimples in my youth and know well how frustrating and depressing that can be. Back 5-10 years ago, I spent a lot of time trying to find out why and how acne vulgaris develops, and over time, I gradually started to put the pieces together.

The fact that something is normal doesn’t necessarily mean that it’s natural

Today, in many countries, including the U.S., more than 50% of the population is overweight; hence, it could be argued that being overweight is the norm. If you’re lean, you’re in the minority. However, if we look at things from an evolutionary perspective, a different picture emerges. Throughout the vast majority of our species’ evolutionary history, virtually all humans had a body mass index of below 25. This statement is supported by a large body of evidence, including body composition data derived from studies investigating the health and physical fitness condition of ancestral, non-westernized humans (1, 2). All animals that live in an environment for which they are genetically well-adapted are fairly lean. Humans are no exception.

A similar picture emerges for acne vulgaris. The fact that it’s today normal to get acne doesn’t mean that getting acne is a natural part of being human. Actually, the weight of the evidence clearly suggests that it’s not. Skin doesn’t fossilize, and our primal ancestors obviously didn’t take pictures of themselves, so we don’t know exactly what our forebears’ skin health and complexion was like. However, we do know how contemporary hunter-gatherers and non-westernized people look like.

Have you ever seen a picture of a hunter-gatherer? Chances are you have, at least if you’ve been reading this blog. Did you see any pimples? No… Well, that’s not surprising. Hunter-gatherers, as well as other non-westernized, traditional people, don’t seem to get acne. They don’t use moisturizers, lotions, or any of the other products that the modern woman puts on her skin every morning, but their skin looks nice and is free of pimples nonetheless. Their skin obviously doesn’t glow like Jennifer Lawrence’s after it’s been covered in massive layers of make-up and retouched in photoshop, but it looks healthy! It looks natural!

Maybe the fact that they don’t use all of the lotions and creams that the modern woman keeps in her bathroom cabinet is part of the reason why they have such good-looking skin. I’m certainly convinced that it is. While applying a white concoction of chemicals of questionable safety onto your skin can help cover up some imperfections and make you look better over the short-term, it will likely make your skin less healthy and worse-looking over the long-term.

The prevalence of acne is very low among hunter-gatherers and other non-westernized, traditional groups

Okay, let’s get back to the issue at hand. A few pictures of some good-looking hunter-gatherers obviously don’t constitute proof that acne vulgaris is a disease of civilization. It’s merely an interesting observation. To really be able to say that this skin condition develops as a result of evolutionary mismatches – the culprit of all diseases of civilization – we need some hard data. Do we have that? Yes, we do. Thanks to some bright researchers who’ve opened their eyes to the possibility that studying ancestral human populations could yield some clues as to why we get sick, it’s now well-established that acne is indeed a modern disease – a disease that was rare in the past, but that’s highly prevalent today. At least it’s been firmly established in my mind, based on the literature I’ve read.

In order to keep this article short and concise – I know people, myself included, have a short attention span when reading stuff online and prefer that the authors of the articles they read get to the point quickly – I won’t get into all the science in this area. However, I would like to highlight the results of one recent study, entitled The blemishes of modern society? Acne prevalence in the Dogon of Mali (3). This study was published earlier this year and is the latest in a growing list of scientific articles that question the popular idea that getting acne is a natural part of growing up.

The authors of the study looked into the prevalence and severity of acne in Dogon adolescents in Mali, West Africa. The Dogon are no hunter-gatherers, but they are not fully industrialized either – far from it. Among other things, they don’t eat highly processed foods, they don’t use contraceptives, and they don’t sit at a computer all day long. They lead a simple life; one that bears some resemblance to that of ancient humans. Some of the people examined as part of this study did have acne; however, in most cases (90%), it was mild or very mild. In total, the prevalence of acne in the cohort was 28%, which is markedly lower than in industrialized societies (85%+).

Here’s what the researchers had to say in their concluding remarks:

Acne is similar to the ‘diseases of civilization’ in being promoted by the pro-inflammatory properties of modern diets. The low prevalence and severity of acne in the Dogon supports the mismatch hypothesis and suggests that acne should join the list of diseases of modern lifestyles. (3)

The results of this study are not surprising to me. It makes sense that these people do get some pimples, but not as many as contemporary, industrialized humans. Earlier studies have shown that the prevalence of acne is even lower among populations that are less westernized than the Dogon. For example, as part of the Kitava study, Dr. Staffan Lindeberg examined 1200 subjects, and found that none of them had acne (4). Similar results were found in a study of the Aché hunter-gatherers (4). In other words, the prevalence of acne seems to increase as you go from populations that live in environments that are similar to humans’ Environments of Evolutionary Adaptedness (EEA) towards more and more industrialized populations. This is exactly what one would expect to see if acne vulgaris is indeed a disease of civilization.

Resolving the mismatch

Acne vulgaris is similar to the other diseases of civilization in that its primary culprit is an evolutionary mismatch. In order to prevent and treat acne vulgaris, this mismatch has to be resolved. I’ve talked a lot about how to go about doing this here on the blog in the past, so that’s not something I’m going to do again here.

What I would like to say is that I believe, based on my experience and everything I’ve read, that dysbiosis of the skin and gut, hormonal imbalances, and chronic inflammation are at the root of acne vulgaris. This notion is supported by a growing body of evidence (4, 5, 6, 7, 8). Many different behaviors can contribute to causing these problems, including the use of “toxic” skin care products, consumption of an unhealthy diet, and antibiotic use.

Genetics obviously also play a role in acne vulgaris, but it’s unlikely to be the primary etiological factor in most cases, a statement that’s supported by the fact that the global prevalence of acne seems to have increased dramatically over the past millenia, despite the fact that our genes haven’t changed that much. The weight of the evidence suggests that, in most instances, acne develops not as a result of “bad genes”, but rather by the expression of ancient genes in a novel environment, including perhaps suboptimal epigenetic programming during the early years of life.

My general advice to anyone who suffers from acne would be to adopt a species-appropriate diet, stay away from “toxic” skin care products (the best course of action is likely to use little or no skin care products at all (your skin is perfectly capable of taking care of itself)), and take better care of their microbiota. Microbiome restoration may be the key to treating acne. These actions may not bring about perfect, blemish-free skin, at least not for everyone, but they should cause a marked reduction in acne severity in most cases, given that a good treatment protocol is set up and adhered to.

In the future, I may write another post in which I take a more comprehensive look at the etiology of acne vulgaris, if I feel that’s something people are interested in reading about. I don’t claim to have all the answers, but I do feel I have a pretty good understanding of what causes this sometimes debilitating skin disorder.

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About Eirik

Eirik Garnas is the creator and owner of Darwinian-Medicine.com. His longstanding interest in nutrition, medicine, and health was spurred by his desire to enhance his athletic performance and physique and overcome various health problems that had come to dominate many aspects of his life. Eirik is formally trained as a nutritionist and holds a bachelor's degree in Public Nutrition and a master's degree in Clinical Nutrition. Additionally, he's coach/trainer schooled at the Norwegian School of Sport Sciences. Over the years, Eirik has gone through several structured courses in order to improve his coaching skills, worked with an assortment of clients, both via the web and in real life (see client testimonials), and developed guides and articles for a variety of health and fitness magazines and websites.

Reader Interactions

Comments

Hi Eirik. These articles are appreciated. Both my brother and I had acne growing up, although we ate a healthy home-cooked diet with plenty of protein, fresh fruit, and vegetables. I still have problems with blocked pores around my nose and chin, although I eat a mostly Paleo diet and put very little product on my skin, so I feel there is more to it than diet alone. Doctors are no help as the products they prescribe are much too harsh. I would be definitely interested in more information on this subject as it comes available.

On a slightly different topic, I was reading about Tom Brady’s diet yesterday. In case you don’t keep up with American sports, he is the quarterback for the New England Patriots. He is 39 now and plans to play another 6 or 7 years. Most pro quarterbacks are finished by the time they reach his age since football is very rough and demanding; yet he still seems to be at the top of his game. He attributes this mostly to his diet, which is healthy enough in most respects but rather limited and very strict. I was wondering what your take would be on what he eats–whether it’s due to good food or exceptional genes. Obviously he gets plenty of exercise, which can’t be overlooked.

Absolutely! That’s one of the key points I want to get across with the article. Some scientists and health practitioners have made the case that acne can be cured with diet alone. I think this view is overly optimistic.

People with mild-moderate acne and a fairly healthy microbiota may get away with “just” changing their diet; however, in cases where the microbiota of the skin and/or gut is highly degraded and imbalanced, adopting a healthy diet is rarely going to be sufficient to bring about a complete resolution of chronic inflammation and repair of the microbiota.

As pointed out in the article, other factors play a role as well. However, I think the microbiome (skin and gut) and diet are the two major ones.

I know who Tom Brady is, and I’ve heard about his diet. The impression I’ve gotten from the articles I’ve read is that he eats fairly healthy. No doubt his diet has contributed to making him as fit as he is. That said, I don’t know specifically what he eats, so I can’t give a detailed assessment of his diet.

I wonder if modern teen turmoil, emotional angst etc is also related to inflammatory diet and poor microbiota. I have read in the past that in other non-western cultures, teens don’t go through emotionally tumultuous teen years the way it’s considered ‘normal’ in the US.

As a nearly 30-year-old non-palaeo woman, I had mild-moderatte teenage cystic acne but it exploded when I turned 20: what also happened when I turned 20? I started college and as a very shy person, my anxiety was through the roof (I was homeschooled through high school so less there). I have also had irregular cycles all of my life, but they became moreso when I started graduate school, which was the second really stressful (and depressing) part of my life. After I had been visiting a derm for while and using his harsh products to control my acne, it got steadily worse despite what I did.

Stress is also something that more primitive societies have less, or maybe different kinds of stress. Not that I think it’s the cure to acne – surely, how do you really cure stress? Our entire society is stressful, so maybe we are in a perpetual state of hormonal imbalance. Until reccently I ate a poor diet consisting of high sugar and have taken anti-biotics my entire life for different reasons and I think it predisposed me for cystic acne, and stress really made it worse.

I am working on getting my hormones balanced and reducing stress and my skin has responded well. I take supplements which also help. My skin finally started clearing when I eliminated dairy and took vitex, and my cycles improved some when I cut out soy. I still fight some mild and intermittent acne.

All this to say… stress is one the last pieces of my acne puzzle that I am working on. In the meantime, I am looking at bone broths to help my gut.

I agree that psychological stress plays a role in the pathogenesis of acne. The reason I didn’t mention it directly is not that I don’t think it’s important, but that it’s “one level below” the causal factors I talk about. I point out that chronic inflammation, dysbiosis, and hormonal imbalances seem to drive the development of acne. Several factors can contribute to causing these issues, including chronic psychological stress, antibiotic use, consumption of processed food, and much more. The thing that all of these things have in common is that they are a part of the big pile of evolutionary mismatches that affect contemporary humans.

Anyways, thanks for pointing out that stress is important. In retrospect, I see that I perhaps should have paid more attention to it in the article.

There’s a problem with your recommendation to go cosmetic-free in that many fair-skinned people live in places where their skin is ill-suited to the environment– that is, very sunny ones. So many of us need to use sunblock, which is going to disturb the microbiome with its preservatives & such. You can’t win it seems! Too bad our ancestors had to decide to try to conquer places they weren’t evolved to live in.

I acknowledge that going completely cosmetic free is not a viable option for everyone. That’s why I didn’t make a strict recommendation to avoid all skin care products.

As for sun exposure, it is, as you point out, important to factor mismatches in space into the equation. What I would like to point out though is that even fair-skinned people who live in sunny places can often make do without sunscreen, as long as they gradually build up a protective tan and cover up (e.g., wear a hat, clothes) if they’re out during the warmest part of the day. Obviously, if they are going to lie on the beach or otherwise expose themselves to a lot of sunlight, they may have to use a sunblock to avoid getting burned. I would then recommend choosing a non-toxic brand that contains as few problematic ingredients as possible.

Oh I do so agree that it is a result of biome depletion and inflammation, I recall years ago seeing a young Indigenous woman in Guatemala with acne. I nearly fell over – it was so out of place. Nobody had pimples there! Of course, I realised all of a sudden – it wasn’t genetics. So many other things I could add to this list. Why don’t the Indigenous babies in Guatemala cry? They are carried everywhere, it’s true – but I carried by children too and they screamed constantly. Reflux and gastro-intenstinal upset is so common in western babies it’s normal. “Babies cry – that’s what they do” a Paediatrician will say to a desperate mother. NO THEY DON’T IN GUATEMALA! Further additions for you to investigate – PMT and morning sickness. I’m told this is unheard of in Papua New Guinea by a friend born there, and seriously – what evolutionary purpose can vomiting all day in pregnancy have?

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[…] seem flawed and damaged. Many of us have or will develop shortsightedness, heart disease, and acne vulgaris; our bones get fragile and weak when we get older; and over time, deleterious mutations develop […]

[…] They tend to have well-developed jaws and dental arches and good posture (1, 3, 4). Furthermore, they rarely or never get acne and have good eyesight (1). These traits form the evolutionary phenotypic norm, in a narrow sense, […]